Top 20 "Do Nots"

So I'm trying to compile a list of 20 things never to do in the ED (humor and jokes aside but unless they're good....). So I can pass this off to our interns and residents. Something quick, one liner, but true.

Like:

Stone Heart - Don't do it. Don't give calcium to a person on digoxin (true or not, its a good one liner to remember).

Don't withold oxygen from a hypoxic patient out of fear of the chronic COPD respiratory depression phenomena.

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i saw an ortho resident attempt this on a sexual assault victim with multiple pelvic fractures. she had been at another hospital without pain meds for 3 days. despite being a med student on an audition rotation, i let him know it was not cool at all and got the attending involved.

kinda glad i didn't match there cuz this guy was a major tool and always seemed to be the one on-call.

I don't necessarily agree with this. The way our program/shifts are structured, procedures are signed out. My class, and I know the classes above us, all agreed to sign out procedures if we needed too (and it doesn't happen often) unless it would be considered part of your PE or an extension of your PE (ultrasounds). I think this is very dependent on how things are structured during residency. Now there is one caveat...I wouldn't do this in an actual job setting as an attending.

Not that anyone in an Emergency Med residency would even think of doing this but ....

Please don't call Family Med, IM or then Hospitalist to admit a patient to the ICU who just rolled into the door in cardiac arrest.

I swear this has happened to me while working as an FM resident in a community hospital ED staffed mostly by FM board certs. I looked at the doc and said "do you want me to admit them to heaven or the ICU?"

"Do not cherry-pick and leave the vag bleeds, peds patients, and lacs to your fellow residents/attendings."

I never understood this one though because I actually like the vaginal bleeds. I love to do pelvics. It's another cool procedure in my book. I mean it takes skill, just like a central or a lac repair or something.

there is one caveat...I wouldn't do this in an actual job setting as an attending.

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If you know you shouldn't do something in an "actual job" why would you do it in residency? Unless you have a plane to catch and are straightforward about asking the person taking over for you to something, the last thing that a person coming on shift diving into a couple of new patients needs is to spend an hour doing cleanup on your signed out patient.

From the patient's perspective, it is difficult enough to trust someone you've spent maybe 15 minutes with to let them do something as invasive as a pelvic or an LP on you (or your loved one). It doesn't get any easier when someone walks into the room essentially saying "I don't know you, but I've heard some stuff about you, and now I'm here to do x to you".

If you know you shouldn't do something in an "actual job" why would you do it in residency? Unless you have a plane to catch and are straightforward about asking the person taking over for you to something, the last thing that a person coming on shift diving into a couple of new patients needs is to spend an hour doing cleanup on your signed out patient.

From the patient's perspective, it is difficult enough to trust someone you've spent maybe 15 minutes with to let them do something as invasive as a pelvic or an LP on you (or your loved one). It doesn't get any easier when someone walks into the room essentially saying "I don't know you, but I've heard some stuff about you, and now I'm here to do x to you".

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It's the culture in our program...that's all there is to it. Our class has decided that this is the way we want to do things. No one is "cleaning anyone's mess up", we're helping each other out get out on time. That's what we have decided to do. They aren't going to be there any longer by helping a classmate out. Besides...sometimes you get called away on a flight towards the end of your shift and there is a ton of stuff left to do...again we call it helping each other out. It doesn't happen on a daily basis, but it happens.

We have decided to sign out procedures to the other residents at shift trade. But a pelvic or rectal is not a "procedure" it is part of the physical exam and can't be signed out. As far as doing procedures on people you have never met, it is just the way our program works. The second year residents do all procedures in the trauma bays, so on a daily basis we walk up to someone we have never met and do an CV line, A line, tube, lp, etc. We have a little phone and when the R3 in the trauma bay calls we come do the procedure. So signing out procedures to be done to the oncoming resident likely makes no difference because neither of us "know" the patient. This helps us get out on time because we do a ton of procedures and fly as R2s and manage an 8 bed pod. Obviously we don't sign out airways because those can't just wait!

I think it also depends on how you present yourself to the patient and family (first off many patient's getting these procedures are so sick they don't care at the time) and you don't just walk up and say "I don't know you, but I've heard some stuff about you, and now I'm here to do x to you." You say, hi I'm Dr. X, the procedure physician here at UC. I understand you need x because of X. My understanding is you have already discussed and been consented for x. Briefly, this is what that procedure is, this is how it is done, do you have any questions? Believe me it works very well. Many people like it because they feel like you are the "procedure doc" that does all of these procedures so you are experienced (which is true and not a false impression because we are doing a ton of procedures) and they feel like you are completely dedicated to them and their procedure at that moment, rather than the busy R3 that they see running all over the resus bays and dept (again you can shatter this belief if you get a flight, but that is the way it goes).

As for not signing out patients, at my program, we used to not sign out things and as a result our 12-hour shifts started to routinely stretch out to 13 or 13-and-a-half hour sifts with occasional 14s.

This was ridiculous, the only defense being to become a slacker on the last couple of hours of your shift to avoid arriving at the end with three or four really complicated patients who you can't disposition until labs or studies come back.

Most of us now accept signouts from our classmates with no questions asked.

Oh, and I still like doing procedures like lines and LPs so I don't mind getting them.

and nowadays, we shouldnt be reflexively giving iv lopressor anymore in the ED for ACS...especially if they're tachy

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Unfortunately we have been saddled with the CORE measures obligations by our hospitals so where I am the EP is responsible for initiating B blockers. We usually give 25 of PO Lopressor. It would be better left for the internists or cards but when you've got to meet CORE measures it's always easiest to bully the contract docs.

The primary author mentioned that although carvedilol has not been studied in this population, it may be show itself as an option, even in acute cases. It's thought that it has a more balanced profile versus labetalol, with more a1 blockade. Interesting stuff...!
And Flopotomist, if you're a dork, then I'll join you in the corner with the "dunce" cap!

Hardly my friend. The real dorks are the ones who think that memorizing "Blueprints Medicine" or "Step Up to the Wards" is going to give them all the knowledge they need to know.

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I completely agree with the above!
Journals are fantastic and I will admit that I'm rather "addicted" to reading articles. It's always exciting to find out new things and review articles with concise overviews of the pathology, diagnosis, and treatment are a "treat" to read.
There's a large component of mental masturbation, but trust me, you'll be a better doc for keeping up and being inquisitive, you can't go wrong there! I'm confident in saying that even as a MS 3-4.

I completely agree with the above!
Journals are fantastic and I will admit that I'm rather "addicted" to reading articles. It's always exciting to find out new things and review articles with concise overviews of the pathology, diagnosis, and treatment are a "treat" to read.
There's a large component of mental masturbation, but trust me, you'll be a better doc for keeping up and being inquisitive, you can't go wrong there! I'm confident in saying that even as a MS 3-4.

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Awww, look its an internist in the making. How cute!

Ya know I'm just giving you grief.

If you actually enjoy reading journals than more power to you. I'm glad we have people like you.

If you actually enjoy reading journals than more power to you. I'm glad we have people like you.

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It's true, it's true...
But what can you do other than go with it? Not like it's all journals or all articles...gotta be good and interesting, clinical too...basic science is generally too dry and less interesting to me.

I worked with a plastic surgeon who would argue that it didn't matter what you closed with as long as you take it out early enough. Not that I'm advocating staples, but they would give a better result taken out at day 3 or so than an fine suture left in for two weeks.

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